hiv outcomes beyond viral suppression · hcv, hepatitis c virus; ost, opioid substitution therapy;...

1 - ASHM, Sydney 2017 @JVLazarus

Prof Jeffrey V. Lazarus [[email protected]]CHIP, Rigshospitalet, University of Copenhagen, WHO Collaborating Centre on HIV and Viral HepatitisAssociate Researcher, ISGlobal, Hospital Clínic, University of BarcelonaBoard Chair, AFEW International

HIV outcomes beyond viral suppression


Do you think PLHIV are receiving the services they need to prevent and treat comorbidities

in your country?

No, services need improving to care for comorbidities in PLHIV

Somewhat, only some areas have suitable services available

Yes, suitable services are available

Do not know

PLHIV, people living with HIV.


Do you know the leading causes of death among PLHIV in your country?

Yes

No

Do not know



Do you know the leading causes of hospital admission in PLHIV in your country?


Yes

No

Do not know


Over the last three decades HIV/AIDS care has transformed markedly1

Understanding the virus and providing palliative care for those with HIV/AIDS

The advent of antiretroviral therapy

Now in the decade where long-term living is a reality

1. Chu C and Selwyn PA. J Urban Health 2001;88:556–66.

Why ‘beyond viral suppression’?Because HIV long-term living is a reality


The UNAIDS ‘90-90-90’ targets … time for a change?

90% 90% 90%

Diagnosed On treatment

Virally suppressed

90-90-90 An ambitious treatment target to help end the AIDS epidemic. Available at: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf. Accessed July 2017.

Setting targets and measuring progress ‘beyond viral suppression’

The need for a new paradigm

The current state of the strategic response to HIV


Fast-Track Cities: Enhancing HIV care in 80 cities around the

world to achieve 90-90-90 targets

31 cities in Africa1Abidjan (Côte d’Ivoire), Accra (Ghana), Algiers (Algeria), Bamako (Mali), Bangui (CAR), Blantyre (Malawi), Brazzaville (Congo), Casablanca (Morocco), Cotonou (Benin), Dakar (Senegal), Dar es Salaam (Tanzania), Djibouti (Djibouti), Douala (Cameroon), Durban (South Africa), Freetown (Sierra Leone), Johannesburg (South Africa), Kigali (Rwanda), Kinshasa (DRC), Lagos (Nigeria), Libreville (Gabon), Lilongwe (Malawi), Lubumbashi (DRC), Lusaka (Zambia), Makeni (Sierra Leone), Maputo (Mozambique), Nairobi (Kenya), Ouagadougou (Burkina Faso), Ouesso (Rep. of Congo), Pretoria (South Africa), Windhoek (Namibia), Yaoundé (Cameroon)

15 cities in Latin America/Caribbean1Buenos Aires (Argentina), Curitiba (Brazil), Havana (Cuba), Kingston (Jamaica), Mexico City (Mexico), Montevideo (Uruguay), Panama City (Panama), Port-au-Prince (Haiti), Quito (Ecuador), Rio de Janeiro (Brazil), Salvador de Bahia (Brazil), Sante Fe (Honduras), Santiago (Chile), San Miguelito (Panama), São Paulo (Brazil)

16 cities in Europe1Amsterdam (Netherlands), Athens (Greece), Barcelona (Spain), Berlin (Germany), Brighton and Hove (England), Brussels (Belgium), Bucharest (Romania), Cascais (Portugal), Geneva (Switzerland), Kyiv (Ukraine), Lisbon (Portugal), Madrid (Spain), Odessa (Ukraine), Paris (France), Porto (Portugal), Seville (Spain)

5 cities in Asia1Bangkok (Thailand), Delhi (India), Jakarta (Indonesia), Melbourne (Australia), Mumbai (India)

1 city in AustralasiaMelbourne (Australia)

About fast-track cities. Available at: http://www.iapac.org/cities/. Accessed July 2017.

Accelerate and scale-up existing programmes and resources to support cities with a high HIV burden to achieve the global UNAIDS targets by 20201

A global partnership supported by: Paris, IAPAC, UNAIDS, and the UN-Habitat1

12 cities in North America1Atlanta (USA), Baltimore (USA), Denver (USA), Mexico City (Mexico), Miami (USA), New Orleans (USA), New York City (USA), Oakland (USA), Phoenix (USA), Providence (USA), San Francisco (USA), Washington DC (USA)

IAPAC, International Association of Providers of AIDS Care; UNAIDS, The Joint United Nations Programme on HIV/AIDS.


The continuum of HIV servicesAn organising framework

Global health sector strategy on HIV, 2016–2012. Available at: http://apps.who.int/iris/bitstream/10665/246178/1/WHO-HIV-2016.05-eng.pdf?ua=1. Accessed July 2017.


The continuum of HIV servicesNational monitoring examples

Vietnam Switzerland

Adapted from: Lazarus JV, et al. BMC Medicine 2016;14:94.


Why is a new paradigm needed?


Health challenges: Ageing

The age profile of PLHIV is changing

2012:Median age 48 yrs

(IQR:45‒53)Age at HIV diagnosis: 43

2003:Median age 40 yrs

(IQR:37‒44)Age at HIV diagnosis: 35

25

20

15

10

5

0

Perc

enta

ge o

f pat

ient

s

20 30 40 50 60 70 80

Age

Age distribution of HIV+ patients attending Modena HIV Metabolic Clinic (MHMC)1

Adapted from: Guaraldi G, et al. 4th International workshop on HIV and ageing 2013.



Health challenges: Comorbiditiesand multimorbidity

The risk of experiencing other illnesses is higher in PLHIV

Adapted from: Guaraldi G, et al. PLoS One 2015;10:e0118531.

CVD, cardiovascular disease; HTN, hypertension; T2DM, Type 2 diabetes; CKD, chronic kidney disease; PLHIV, people living with HIV.

CVD HTN T2DM CKD Multimorbidity


Health challenges: Closing the gap

HIV as a long-term chronic illness brings a new set of challenges:- No longer about prolonging life

with HIV but ensuring QoL1

- Slowly starting to be addressed in global policy developments1

Closing the morbidity and mortality gap between PLHIV and the general population:- Early testing and care1

- Long-term treatment strategies1

- Well tolerated and convenient ART1

- Holistic approach to health1

ART, antiretroviral therapy; PLHIV, people living with HIV; QoL, quality of life.1. Global health sector strategy on HIV, 2016–2012. Available at: http://apps.who.int/iris/bitstream/10665/246178/1/WHO-HIV-2016.05-eng.pdf?ua=1. Accessed July 2017.


Responding strategically: ‘Beyond viral suppression’

Lazarus JV, et al. BMC Medicine 2016;14:94.


‘Beyond viral suppression’: Time for a ‘fourth 90’


90% 90% 90%

Diagnosed On treatment

Virally suppressed

90%

Good health-related quality

of life


‘Beyond viral suppression’: Operationalising the ‘fourth 90’

Vietnam Switzerland


ART, antiretroviral therapy; PLHIV, people living with HIV.


Promising steps: The long view coalition: Driving progress toward the ‘fourth 90’

An imagined future by the HIV: The long view coalition1

• People with HIV will see HIV specialists less frequently

• Care is delivered via an integrated care model• Pre-emptive screening is routine e.g. chronic

conditions• Individuals seek online support from peers• Personal health tools collect data but also

provide guidance and make predictions• Real-time monitoring and support is the mainstay• Artificial intelligence doctors are commonplace• Virtual clinics oversee large geographies• Machine learning supports the information

processing and decision-making of human doctors

• Data drives forward the standard of care at an individual and population level

Life expectancy is at an all-time high1

New infections

havedropped

substantially1

Detecting the undetectable

1

1. A report from HIV: The long view coalition Europe. Available at: http://hivthelongview.eu/HIV_TheLongView_EU_Report.pdf. Accessed July 2017.


A people-centred health systems approach


… Through a people-centred health systems approach

Achieving the ‘long view’ vision and ‘fourth 90’ target:

How do we get there?

Adapted from: van Olmen et al., BMC Pub Health 2012;12:774.


Promising steps: The EuroSIDA clinic study

1. Lazarus JV, et al. BMC ID 2016;16:335.

P er c

ent a

geo

f clin

i cs

(%)

Toward a people-centred health systems approach and the ‘fourth 90’

Promising steps: The EuroSIDA clinic study

Source: Lazarus JV, et al. BMC ID 2016;16:335.

Perc

enta

ge o

f clin

ics,

%


A case study of integrated treatment: Two models in Porto, Portugal

Dedicated outpatient care centre at Joaquim Urbano Hospital1

Multidisciplinary team care with combined protocols

Multiple health service collaboration1

Existing health programmes collaborate to deliver treatment at a patient convenient location

Individually tailored Marked improvements in

treatment adherence observed

1. Accessibility and integration of HIV, TB and harm reduction services for people who inject drugs in Portugal – a rapid assessment. Available at: http://www.euro.who.int/en/countries/portugal/publications2/accessibility-and-integration-of-hiv,-tb-and-harm-reduction-services-for-people-who-inject-drugs-in-portugal-a-rapid-assessment. Accessed June 2017.

HCV, hepatitis C virus; OST, opioid substitution therapy; TB, tuberculosis.* Includes pulmonary diagnostic centres, HIV/HCV clinics, drug treatment centres, outreach teams, and sheltered housing.

INFECTIOUS DISEASE

SPECIALISTS

PSYCHIATRISTS

PSYCHOLOGISTS

SOCIAL WORKERS

NURSESMULTIDISCIPLINARY

TEAM

ONSITE & DAILY TREATMENT

HIVOST

TBHCV


Toward a people-centred health systems approach and the ‘fourth 90’

Promising steps: The beyond viral suppression coalition


What do health outcomes ‘beyond viral suppression’ mean for health systems?


The change in health systems: Three levels of performance monitoring

Proposed comparativeHIV indicators

LEVEL 1: What are European health systems monitoring?

Comparative measures of health access and outcomes

for PLHIV LEVEL 2: How are European health systems performing?

Countries to integrate/adapt as appropriate to country

context

Additional indicators LEVEL 3: Additional indicators for assessing access to

health services and outcomes



A people-centred health systems approach to going ‘beyond viral suppression’

Where do you fit in?

How can health care providers influence leadership/governance?

How can health care providers influence service delivery?

How can health care providers influence resources?

Adapted from: van Olmen et al., BMC Pub Health 2012;12:774.

Resources

Leadership & Governance

Service Delivery


Thank you

Prof Jeffrey V. Lazarus [[email protected]

hiv outcomes beyond viral suppression · hcv, hepatitis c virus; ost, opioid substitution therapy;...

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